Colgan Air Flight 3407 Human Factors Analysis
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Utah Valley University *
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Course
2130
Subject
Industrial Engineering
Date
Dec 6, 2023
Type
Pages
2
Uploaded by CommodoreElectronManatee46
Jocie Harding
Colgan Air Flight 3407 Human Factors Analysis
Colgan Air Flight 3407 occurred on February 12, 2009. The flight was going from
Newark, New Jersey to Buffalo, New York. Before landing in Buffalo, the plane disappeared
from radar to be found in Clarence Center, New York after falling from the sky. Using the SHELL
model to analyze this accident provides insights to the elements that influenced how this crash
happened. The parts of the SHELL model are, Software, Hardware, Environment, and Liveware.
Liveware has 2 parts. The first being the person(s) involved and second being interactions
between people, workplace, and flight crews. Going through different parts of the SHELL model
using Flight 3407 will improve information about safety in complex systems like aviation.
First, the environment. The Environment part of the SHELL model includes factors like
weather conditions. Weather is a huge part to take into consideration when talking about
aviation safety. The weather that night was snowy and windy. Along with some fog in Buffalo.
This kind of weather brings about icing. Icing on an aircraft can decrease flight performance
significantly and causing drag. With Flight 3407, the crew failed to take into consideration the
effects icing would have on their air speed. Leading them to incorrectly check software.
Software includes things like procedures, rules, checklists, training, and regulations. In
the case of Flight 3407, the first officer did not have experience with icing and limited experience
with the aircraft. So, when the plane stalled, she incorrectly responded to the stall by retracting
the flaps, reducing the amount of lift and therefore causing an even slower airspeed. They also
put off doing checklists due to the conversation they were having when they were supposed to
be abiding by the “sterile cockpit” regulation which prevents unnecessary conversation during
important parts of flight, like landing. This can also be attributed to the fatigue the flight crew
was experiencing.
Individual parts in the SHELL model are taken into account in the Liveware. This
encompasses things like fatigue, communication, and decision-making. While the first officer of
Flight 3407 was fatigued, so was the captain. Captain Renslow’s decision
-making was majorly
affected by his fatigue when he pulled up in response to the stick shaker. Causing the plane to
stall. When he should’ve pushed down and increased power in response to the stick shaker to
avoid a stall.
When looking at Flight 3407 and its effects on safety in aviation, some very important
things can be learned on what actions to take to avoid something like this from happening
again. Like providing adequate training on how to deal with different weather conditions and
enhancing weather monitoring systems. Along with stricter regulations on pilot fatigue and
assessments that crew members are adequately prepared for any situation that may happen
before, during, and after flight. The SHELL model can help point out the weaknesses and
strengths in different systems so that we can better implement strategies that prevent accidents
like the Colgan Air Flight 3407. And help take into account human factors to better ensure safe
flights and will collectively lead towards safer operations in the aviation industry.
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